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I <br /> • • STATE ID NUMBER 00000062849003 <br /> CONTAINER CONSTRUCTION <br /> E. f ) 01 RUBBER LINED ( ) 02 ALKYD LINING ( 1 03 EPDXY LINING ( l 04 PHENOLIC LINING ( l 05 GLASS LINING <br /> (X7 07 UNLINED ( ) 08 UNKNOWN ( 7 09 OTHER: <br /> F. f 1 01 POLYETHLENE WRAP ( l 02 VINYL WRAPPING [ ) 03 CATHODIC PROTECTION ( ) 04 UNKNOWN (X7 05 NONE <br /> ( ) 06 TAR OR ASPHALT f ) 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f. ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCR€TE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) (x' 04 PRESSURE ( ) 05 SUCTION f 1 06 UNKNOWN ( ) 07 NONE <br /> VII LEAK DETECTION <br /> f ) <br /> 01 VISUAL (X) 02 STOCK INVENTORY ( ) 04 VAPOR SNIFF WELLS ( 1 05 SENSOR INSTRUMENT `I <br /> ( ) 06 GROUND WATER MONITORING WELLS (XCf 07 PRESSURE TEST ( ) 09 NONE A 10 OTHER( �-AwlAr �q� <br /> n� C`7`fjr <br /> VIII CHEMICAL COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO IV-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (00 NOT USE COMMERCIAL NAME) <br /> STORED STOPED <br /> ( ] <br /> 01 ( 1. 02 ( ) 03 <br /> ( 1 01 f 1. 02 ( ) 03 <br /> [ 1 Ol 1 ) 02 ( ) 03 <br /> ( ) 01 ( 1 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> ( ) <br /> 01 ( ) 02 ( 7 03 <br /> ( 7 Ol ( ) 02 ( ) 03 <br /> ( ) Ol [ ) 02 ( ) 03 <br /> ( ) 01 ( ) 02 ( ) 03 <br /> f l 01 ( ) 02 1 ) 03 <br /> ■ CHECK STATE BOARD CHEMICAL CODE LISTING FOR POSSIBLE SYNONYMS <br /> IS CONTAINER LOCATED ON AN AGRICULTURAL FAR�C ) YES (X102 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER THE PENALTY OF PERJURY AND, TO THE BEST OF MY KNOWLEDGE, IS TRUE ANO CORRECT. <br /> PERSO FI ING (SIGNATyayr PHONE W/AREA CODE ZW <br /> IP <br /> W}� <br /> FOR L CAL AGENCY USE ONLY <br /> ADMINISTRATING AGENCY CITY CODE COUNTY CODE <br /> CONTACT PERSON PHONE W/AREA CODE <br /> DATE OF LAST INSPECTION IN COMPLIANCE PERMIT APPROVAL DATE TRANSACTION DATE LOCAL PERMIT ID # <br /> ( 1 <br /> 01 YES ( ) 02 NO <br /> HSC04-070185 (10/18/85) PAGE 2 <br />